Provider Demographics
NPI:1205244134
Name:LEWIS, LINDA
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 531
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:FL
Mailing Address - Zip Code:32187-0531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 BREEZEWAY AVE
Practice Address - Street 2:
Practice Address - City:SATSUMA
Practice Address - State:FL
Practice Address - Zip Code:32189-2536
Practice Address - Country:US
Practice Address - Phone:386-227-8068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL233124172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker